Relapse prevention

One of the goals of motivational interviewing is to help the client formulate goals or guidelines for how they would like to be functioning and then explore how substance use either hampers or furthers these goals. Often, this approach has the effect of developing a discrepancy in the client’s experience which can help the client more clearly see how their substance use inhibits the reaching of stated and desired goals.

This approach also allows clients to reach their own conclusions about reducing use. An added benefit is that clients often feel that they are treated more respectfully than in traditional substance treatment programs and that treatment is individualized to meet their goals, which has the effect of increasing their engagement and retention in treatment (Futterman, Lorente, & Silverman, 2005).

While relapse prevention is not a strictly harm reduction-oriented treatment, relapse prevention (RP) techniques can be utilized within the framework of harm-reduction-based treatment as a means of implementing a skills-building/self-monitoring component with an exploration to discover situations that trigger substance use (Marlatt & Donovan, 2005). RP-based treatment begins with the assessment of potential interpersonal, intrapersonal, environmental, and physiological risks for use and the client-specific factors or situations that may precipitate use or relapse into drinking after a period of abstinence.

Clients who have not experienced abstinence focus on events or situations that trigger drug or alcohol binge episodes. Once potential triggers to use and high-risk situations are identified, cognitive and behavioral approaches are implemented that incorporate both specific interventions and global self-management strategies. Specific interventions include teaching effective coping strategies, enhancing self-efficacy, and encouraging mastery over successful outcomes (Marlatt & Donovan, 2005).

In addition, specific cognitive-behavioral approaches such as relaxation training and stress management can be implemented to increase life-style balance (Marlatt & Donovan, 2005). Recently, mindfulness techniques and meditation exercises have been incorporated into the treatment of several behavioral disorders (e. g. borderline personality disorder, depression and anxiety), and preliminary results demonstrate that mindfulness techniques may be a viable, effective adjunct to the treatment of substance abuse (Marlatt & Witkiewitz, 2005).

Within the framework of cognitive-behavioral treatments, approaches utilizing mindfulness techniques have been found to have utility in assisting clients in the process of identifying affective and cognitive factors implicated in many disorders, including maladaptive substance use (Marlatt & Witkiewitz, 2005). Mindfulness techniques work on some of the same mechanisms as cognitive-behavioral based treatments do (Baer, 2003). However, unlike traditional cognitive-behavioral treatments, the difference is not in changing thinking, but in changing the client’s relationship to thoughts and affects.

Incorporation of mindfulness techniques into treatment has been found to be helpful in enabling clients to identify cognitive and affective triggers to maladaptive substance use. They help to develop the ability to tolerate triggers, rather than turning to alcohol to do so, and to allow clients to move towards the acquisition of alternative coping skills (Marlatt & Witkiewitz, 2005). Different harm reduction strategies have been shown to be effective in reducing alcohol related harm. Strategies that have been shown to benefit youth in controlled studies have included broad school based programming, brief interventions (e.

g. safe alcohol use counseling) in outpatient settings, and the use of a drinking diary during Spring Break (Shope et al. , 2001). A school based RCT evaluating a brief curriculum intervention with 10 year follow-up of 554 study subjects showed no effect on self-reported drinking related harms and death (Wutzke et al. , 2002). Some studies examining strategies to reduce alcohol consumption by limiting access to alcohol report their findings as impacts of a harm reduction approach, however in the strict sense, these are abstinence based strategies (Magdenko, 1996).

All of the studies used self-reported measures of harm. One study, that showed no effect, used mortality data and gamma-glutamyl transpeptidase, as a biochemical marker of liver effects due to heavy drinking (Wutzke et al. , 2002). In a retrospective study led by Thornquist (2002), three programs using a harm reduction approach for persons with problems related to heavy alcohol use were evaluated. Two programs were residential programs and one was a case management program for persons living on the street. The aim of all three programs was to reduce inappropriate emergency room visits.

The study was a retrospective examination of health insurance claims before and after entry into the programs. Results included non-significant reductions in emergency room visits, overnight hospitalizations, health care costs and significant drops in detox unit usage (Thornquist, 2002). While harm-reduction-based treatment draws on contributions of the psychodynamic, cognitive-behavioral, and humanistic approaches to working with clients, to date, there has been no empirical evaluation of harm reduction techniques and practices.

The clinical perspectives and interventions used in harm reduction are a way of working with and being with substance users. With the publications of guides to harm reduction work by Denning et al. (2004), Marlatt (1998) and Tatarsky (2002), the field has reached the developmental stage in which more empirical research is needed. Studies of treatment utilizing adaptations of motivational interviewing (AMI) have yielded moderate to large effects and good maintenance over time in the areas of alcohol problems and drug addictions (Burke, Arkowitz, & Dunn, 2002).

In general, treatments incorporating motivational interviewing are more efficacious than no treatment at all. Many outcomes of AMI for alcohol problems are not only statistically, but clinically significant (Burke, Arkowitz, & Dunn, 2002). There needs to be more research assessing the effectiveness of motivational interviewing methods, but motivational interviewing shows much promise as a treatment intervention in substance use.

Irvin, Bower, Dunn and Wang (1999) did a meta-analysis of RP-based techniques in the treatment of alcohol and polysubstance use. Twenty-six studies representing a sample of 9,504 participants were included in the review. The results demonstrated that RP was a successful intervention for reducing substance use and improving psychosocial functioning. In particular, RP was found most effective in treating alcohol use and RP was equally effective across different treatment modalities, including individual and group treatment delivery.

However, RP was originally developed as an adjunct to treatment for alcohol use, so it is not surprising that this meta- analysis found it was most effective for individuals with alcohol problems. The authors concluded that RP is an efficacious treatment, but cautioned that little is known about the moderators and mediators of RP effectiveness. Specifically, very few studies have investigated whether there are individual components of RP that are more influential than others or what the differential effectiveness of RP is across different types of treatment settings (Irvin et al. , 1999).

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